A case study where memory disorder became obvious after ... data/16_97.pdf · Tomoko Kayukawa...

Journal of Human Environmental Studies, Volume 16, Number 2, 2018

97

Union Press

A case study where memory disorder became obvious after disturbance of consciousness:Treatment using a hierarchical model

Makoto Hirumuta (Department of Rehabilitation, Fujita Health University, Bantane Hospital, [email protected])Takaji Suzuki (Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, [email protected])Miho Ohashi (Department of Rehabilitation, Fujita Health University, Bantane Hospital, [email protected])Tomoko Kayukawa (Department of Rehabilitation, Fujita Health University, Bantane Hospital, [email protected])Yoichiro Aoyagi (Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, [email protected])

意識障害改善後に記憶障害が顕在化した一例―階層モデルに沿った介入―

蛭牟田誠（藤田医科大学ばんたね病院リハビリテーション部）

鈴木孝治（藤田医科大学医療科学部リハビリテーション学科）

大橋美穂（藤田医科大学ばんたね病院リハビリテーション部）

粥川知子（藤田医科大学ばんたね病院リハビリテーション部）

青柳陽一郎（藤田医科大学医学部リハビリテーション医学 I 講座）

要約

頭蓋咽頭腫に対する術後に意識障害を認め、意識障害改善後に注意障害、記憶障害を中心とした高次脳機能障害を呈し

た 40 代男性に対し、情報処理過程としての高次脳機能の過程に従いリハビリテーションアプローチを行った。記憶障害

に対しては直接的アプローチに加え、外的補助手段としてメモリーノートを導入した。しかし、記憶障害に対する障害

認識を十分持ち合わせておらず、効果的な導入は困難であった。そこでアウェアネスの概念に沿ったアプローチを実施

した。その結果、WMS-R 等の評価で改善を認めた。また知的アウェアネスの獲得に至り、メモリーノートを自発的に

確認することが可能となった。階層モデルに従い、アプローチをしていくことで症例の現状や段階を捉えやすくなりリ

ハビリテーション介入がよりスムースとなった。

Key wordshierarchical model, awareness, amnesia, inattention, memory notebook

1. IntroductionPractical rehabilitation-methods for patients who suffer from

amnesia are: 1. Direct and repeated training of memory ability; 2. External and internal compensation methods; 3. Cognitive train-ing by improving learning methods, and; 4. Environmental ad-justment (Kato, 2003). Direct intervention upon the nerve mech-anism related to memory does not produce satisfactory effects in patients (Miyahara, 2008), and using a memory notebook is often selected as an external compensation method. However, variations in injuries and symptoms limit the use of a memory notebook and other external assistant-means today (Watanabe, 2002). Anosodiaphoria and the decay of self-motivation are known as obstructive factors when external assistant-means are introduced. (Nakagawa, 2011).

Suzuki (2016a) describes how intervention for patients with amnesia begins with the grasping of consciousness of which the focus is awakening, and the grasping of every aspect of attention functions and emotions, by following the process of cognitive function as a form of information-processing (Figure 1), Osaka

(1996) advocated that the hierarchical model of the conscious (Figure 2) is constituted with awakening at the bottom, aware-ness in the middle as attention to externality, and self-conscious-ness as attention to the self at the very top. Crosson et al. (1989) defined awareness as “the ability to recognize the disorder oc-curring to him/herself,” and he formulated a hierarchical model with three levels consisting of intellectual awareness, emergent awareness, and anticipatory awareness (Figure 3). As shown above, it is necessary for interventions for patients with amnesia

Figure 1: Process of cognitive function as a form of information-processingNote: Extracted from Suzuki, T (2016b) in Reference after making some changes.

input output

Cognition Action

planning

Consciousness, AttentionEmotion, Memory

Executive function

Reasoning,Decision making,

Thinking,Concept formation,

Language

人間環境学研究　第 16 巻 2 号　2018 年

98 蛭牟田誠他：意識障害改善後に記憶障害が顕在化した一例

to be conducted gradually.In this case history, a memory notebook was introduced as

an outer assistant-means because high-order brain dysfunction, especially amnesia, became evident after some improvements were found for the patient’s disturbance of consciousness. How-ever, as the patient was not fully aware of his amnesia, it was judged that the patient would not respond to the introduction of a memory notebook effectively. As a result, the patient respond-ed better and made some progress after other approaches were made following the concept of awareness. This paper will report on this process.

2. Case presentation• Social history

A male in his 40’s. Right handed (though innate left handed and corrected to being right handed at some stage in his life). University graduate, and worked in the automobile manufacturing industry.

• DiagnosisCraniopharingioma, right frontal-lobe hemorrhage.

• History of present illnessThe patient was treated at an ophthalmology clinic for one and a half years, but as symptoms aggravated, he came to

our hospital. Craniopharingioma was found in his supra-sellar region after being given an MRI test. A month later this, he was admitted into our hospital for surgery. After an operation removing the craniopharingioma, he developed a right frontal-lobe hemorrhage and an operation to remove an intracranial hematoma was performed 2 days later. Physical and occupational therapies began on the 2nd day after the second operation. On the 16th day after the second opera-tion, speech-hearing therapy began.

• AnamnesisUreterolithiasis

• Neuroradiologic findingBefore hospitalization, a growth was found in suprasellar region by an MRI test (Figure 4). On the 11th day after the operation to remove an intracranial hematoma, an new and old hematoma was found in the right frontal-lobe by another MRI test on the head (Figure 5).

• Neurological findingAt the first intervention of speech-language hearing therapy, the patient’s consciousness level was recorded as II-10-20 on the Japan Coma Scale (JCS), and the results for Manual Muscle Testing were 4 for the right upper limb, 3 for the right lower limb, and 3 for both left upper and left lower limbs. Activities of Daily Living (ADL) were scored at 24/126

Awareness

Arousal

Self-consciousness

Figure 2: Hierarchical model of the consciousNote: Extracted from Osaka, N. (1996) in Reference after making some changes.

Emergent awareness

Intellectual awareness

Anticipatoryawareness

Figure 3: Hierarchy of self-awarenessNote: Extracted from Crosson, B. et al. (1989) in Reference after mak-ing some changes.

Figure 4: Brain MRI of prior to surgery

Figure 5: Brain MRI on 11th day after surgery


99M. Hirumuta et al.: A case study where memory disorder became obvious after disturbance of consciousness

points by the Functional Independence Measure (FIM).• Initial assessment

Table 1 shows the results of neuropsychological findings recorded on between the 41th and 55th days after the second operation and test results of neuropsychological findings. The testing for attention function was suspended because the patient could not complete a Trail Making Test-A (TMT-A), even though plenty of time was spent on it. The patient scored 34/36 points for a Raven’s Colored Progressive Ma-trices (RCPM) test. The results for a Wechsler Adult Intelli-gence Scale-Third (WAIS-III) were 89 for verbal IQ, 67 for performance IQ, and IQ79 for all tests, As the patient ob-tained 94 of the group index of working memory and scored 94 for attention/concentration on a WMS-R, it was judged that his working memory was intact. His abilities at thinking and analogy also were sustained since they were not affected by memory disturbance. The results of a Wechsler Memory Scale-Revised (WMS-R) were scale-out except for atten-tion/concentration, and the results of a Rivermead Behavior-al Memory Test (RBMT) were 2/24 points for the standard profile and 0/12 points for screening. As a result, although immediate memory was good, the prospective memory and the recent memory were severely reduced. Observation of his daily life indicated that the level of his remote memory

had also dropped. The result of his Behavioral Assessment of the Dysexecutive Syndrome (BADS) was 95 points ac-cording to the standardized score and the overall section was at average. The patient’s self-motivation level lowered and he was found to be confabulating. Based on the above, the patient was judged as having an overall disturbance of atten-tion and severe amnesia.

• Awareness evaluationThough the condition of cognitive dysfunction, including amnesia and attention, were explained to the patient, he was saying that “he can go back to his job and drive a car.” There was also an incident of him not being able to go back to his room by himself. These episodes indicated that he did not fully understand his disorder and how the disorder could affect his daily life. It appeared that he had not even reached the level of intellectual awareness.

3. Process of rehabilitation interventionsInterventions were made 5 or 6 times a week.

3.1 Direct approaches3.1.1 Intervention to disturbance of consciousness (on between the 1st and 40th days)

Immediately after the initiation of physical and occupa-

Table 1: Test results of neuropsychological findings

Notes: HDS-R: Hasegawa dementia rating scale-revised. RAVLT: Rey’s auditory-verbal learning test.

Name of Test

Initial evaluation(on between the 41th and 55th days after second operation)

Re-evaluation(on between the 76th and 86th days after second operation)

WAIS-III

Verbal IQ 89 99

Performance IQ 67 75

All tests IQ 76 87

HDS-R 10/30 19/30

RCPM 34/36 32/36

WMS-R

Verbal memory under 50 52

Visual memory under 50 75

General memory under 50 65

Attention/concentration 94 94

Delayed recall under 50 under 50

Miyake’s paired verbal associate learning test

Relevant dialogue 3-4-5 5-6-8

Irrelevant dialogue 0-0-0 0-0-2

RBMTStandard profile score 2/24 3/24

Screening score 0/12 0/12

RAVLTList-A play 2-3-3-6-3 3-5-2-5-6

List-A delayed recognition 3/15 13/15

TMTA discontinuance 138 seconds

B – 197 seconds

BADS Total profile score 17/24 –



tion therapies, standing up by using a slope was instructed on and practiced. Oral care, swallow reflex facilitation, and other swallowing training were also conducted at eating scenes as interventions based on speech language hearing therapy. The awakening level was to be improved by stimulating the auditory, visual, pain, and temperature senses.

3.1.2 Intervention to cognitive dysfunction (on between the 56th and 75th days)

A visual cancellation task was conducted as an approach to the disturbance of attention, and the patient was asked to draw circles on all of one type among pictorial figures. Because the level of his continuous attention was found to be lowered, he was relocated to a quieter environment and asked to do simpler tasks. After this, he was given tasks of drawing a circle on all of two types among pictorial figures. Then the difficulty of tasks was increased gradually as he was asked, for example, to put circles on round figures and triangle figures at the same time. He was also asked to check over what he had just done.

An approach to memory function was made together with an approach to attention function after continuous attention improved. Memory tasks using picture cards were repeated and recall time was extended gradually. The number of picture cards was increased as well as decreased in order to adjust the diffi-culties.

The patient’s faculty of orientation was also supported each time in addition to the approaches to disturbances of attention and memory. During these approaches, both positive and nega-tive feedback were given with a view to encouraging the obtain-ment of intellectual awareness.

3.2 Indirect approaches (on between the 55th and 90th days) and environmental coordination, external compen-sation method

On the 55th day after the operation, a memory notebook was introduced as an external compensation method. The patient wrote about dates, his schedule, and other related matters with the nurse every day, and the content was checked during reha-bilitation.

4. Results and process4.1 Evaluation results4.1.1 Consciousness level (the 40th day)

The patient was lucid, and ADL became 103/126 points by the FIM.

4.1.2 As neuropsychological findings (on between the 76th and 86th days)

The results of WAIS-III were IQ99 for verbal, IQ75 for per-formance, and IQ87 for all tests. The results of WMS-R were 52 for verbal memory, 75 for visual memory, 65 for general memo-ry, 94 for attention/concentration, and delayed recall was under

50. The results of RBMT were 3/24 points for the standard profile and 0/12 points for screening. The times recorded for TMT were 138 seconds for TMT-A, and 197 seconds for TMT-B (Table 1). The results of the evaluations show some improve-ments to attention function and memory function, and especially to visual memory.

4.2 Process of using a memory notebookTable 2 shows the process of using a memory notebook,

and changes in contents of speech. On the 61th day after the operation, the patient forgot even the existence of the memory notebook. Reminding him of the notebook was required, but he did not understand the necessity of the memory notebook. We explained him about how and why he was hospitalized during rehabilitation. We also gave feedback about the symptoms and results of his cognitive dysfunction, and we gave the feedback by linking the symptoms to the failures he made during reha-bilitation program. This was done in this way with a view to encouraging him to gain intellectual awareness. On the 68th postoperative day, a notice sheet about the memory notebook was put up on the wall of his room in the hospital as a reminder. The change in the words recorded on the 69th day indicates that he knew he needed to take something during rehabilitation program. On the 83th day the amount of content he wrote in the notebook increased and he could check over the content volun-tarily.

4.3 Changes in contents of speechOn the 55th day after the operation, the patient was thinking

that he could return to work and he could drive. He was denying his disorder completely, and thus an obtainment of intellectual awareness was prompted. On the 68th day, the patient confabu-lated about his hospitalization, saying he came to see his friend in the hospital and he felt ill. On the 69th day, questions about his condition began to appear in his writings. The patient was wondering if he was suffering from some kind of disorder. He said, “I was hospitalized due to amnesia but I don’t know why I was admitted to the hospital.” On the 83rd day he could explain how he was hospitalized. On the 84th day, he said, “I am not good at memorizing, so I want to have training to improve my memory.” He was sensing the necessity of rehabilitation. He had reached the level of an obtainment of intellectual aware-ness. However, it was still difficult for him to recognize how the disorder could affect his life. The patient failed to obtain an emergent awareness while he was in our hospital.

5. DiscussionThis case history is about a patient being found to suffer

from attention disturbance, memory disturbance, and other cognitive dysfunction after the disturbance of consciousness had improved. Using approaches based on a hierarchical model made understanding of the actual status and stages of the patient


101M. Hirumuta et al.: A case study where memory disorder became obvious after disturbance of consciousness

easier and made rehabilitation interventions smoother.

5.1 Direct approaches5.1.1 Intervention to disturbance of consciousness

An initial approach was made to the disturbance of con-sciousness. The disturbance of consciousness is positioned at the bottom in the processes of cognitive dysfunction as a form of information process and in the hierarchical model of conscious-ness. From early stage the patient was given multiple stimuli and given training that including taking a seated position, stand-ing up, and swallow reflex facilitation. As a result of natural re-covery and approach to disturbance of consciousness, significant JCS improvement was recognized.

It was judged that when the awakening level was at a low level, attention would not function, but the consciousness level improved even from the point when immediate recall became possible.

5.1.2 Intervention to cognitive dysfunctionCognitive dysfunction became obvious as the level of con-

sciousness increased. We then focused on caution function and memory function according to the process of cognitive function as a form of information-processing (Suzuki, 2016b). As a re-sult, disturbances of attention function and of memory function were improved. Direct intervention upon the nerve mechanism related to memory does not produce satisfactory effects in pa-tients (Miyahara, 2008). Improvement of disturbance of the at-tention function might have influenced the improvement of the

Table 2: Process of using a memory notebook, and changes of contents of speech

Days after the operation Memory notebook Contents of speech

55th Starts using a memory notebook. Thinking that it is possible to return to work and drive a car.

61th Requires encouragement to use it.No full understanding of necessity of the notebook.

63th Encouraged to be conscious of disease.“I know I forget easily, but I am ok.”

64th Possible to check over writings after encourage-ment.

67th

Encouraged to obtain awareness by using a scar on forehead.“This is a cut caused for removing a clot from nose bleeding.”

68th Put up a notice-paper as reminder about the note-book.

“The reason why I was hospitalized is because I came to see my friend in hospital and I also felt ill.”

69th Understands to carry something with him, but no understanding of what to carry.

“I was hospitalized for amnesia. I don’t know why I was hospitalized.”

76th Possible to open the notebook without being led to it.

83th Increase in writing.Possible to check over writing voluntarily.

“I went to the ophthalmology clinic for my eyes but I was hospitalized for problems in my brain.”

84th “I am not good at memorizing and want to have training to improve my memory.”

87th “I came in for a drop in vision, but I was told about having a tumor and had an operation.”

disturbance of the memory function.

5.2 Indirect approaches and awarenessA memory notebook was introduced at an early stage as an

outer assistant-means together with some direct approaches to cognitive dysfunction. However, the patient was not sensing the necessity of the memory notebook, and thus the usage of a memory notebook was not practical.

Watanabe et al. (2002) suggested that contributing factors towards the practical usage of outer assistant means are: 1. The patient’s consciousness of the disease; 2. The fact of whether the patient had a habit of taking notes pre-clinically and; 3. The necessity for taking notes (as a daily habit) felt by the patient. The patient in this case history was found to have a poor con-sciousness of his disorder and to be failing to obtain intellectual awareness. The process of hospitalization was explained repeat-edly and, as a result, it became possible for him to answer the question of why he was hospitalized. He could understand the situation he was put under. He was also given feedback about the results and symptoms of his high-order brain dysfunction, and the feedback was given by linking it to the failures he made during rehabilitation. Ohigashi (2009) described how it is dif-ficult to make patients with severe amnesia realize their condi-tion. He suggests that it would be more effective if the patients were prompted to know the outcomes of their actions by him/herself, and if compensation methods were used for the pur-pose of prompting the patient to realize his/her condition. The patient in this paper was given feedback repeatedly by making



links to the failures he had made. This worked as a hint for him to realize his condition and he eventually obtained intellectual awareness. Watanabe (2002) suggested that important factors for judging whether patients with amnesia could use compensa-tion means or not are: 1. With or without any disturbance to im-mediate memory, and 2. Intellectual ability indicated by WAIS-R. The patient’s, immediate memory was relatively kept at the beginning of the intervention, but the intellectual ability of WAIS-III showed a decrease. However, on the 78th day after the operation he was possible for him to obtain a score beyond IQ75 on the WAIS-III test. This is the level Watanabe indicated as a line for deciding the possibility of using a memory notebook. The patient obtained intellectual awareness and his status got closer to the conditions given above. These may have worked as factors in increasing the frequency of his usage of the memory notebook, though this has not been established. The reason for this is because the patient has not reached the point of obtaining an emergent awareness. However, the frequency of his using the memory notebook is increasing, and this suggests that the pa-tient is in transition towards obtaining an emergent awareness.

The patient was given feedback by linking it to the failures he made with a view to obtaining intellectual awareness, but it was possible that this could be causing him psychological stress, since his weaknesses and faults were being pointed out. The pa-tient in this case history was transferred to another hospital after he obtained intellectual awareness. But it is possible to make the suggestion that suitable support and interventions are necessary in the period after the obtainment of intellectual awareness. Na-gano (2012) indicated that in order to make patients understand their disorder precisely, it is necessary to provide proper support depending on how much the they grasp about their condition. Knowing what stage a patient is at leads to the precise supply of support.

6. Future tasksInterventions in this case history were given by following

the process of cognitive dysfunction as a form of information-processing and Hierarchy of self-awareness. This made it pos-sible to conduct some approaches suited to the patient.

This study is based on one case history, and thus the ef-fectiveness of the interventions following the models is limited to this case. Studies should be conducted on more cases in the future.

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Miyahara, T. & Kadowaki, Y. (2008). The effectiveness of a memory notebook on self-awareness in a patient with mem-ory disorder. The Journal of Japanese Occupational Therapy Association, 27, 254-264.

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(Received May 15, 2018; accepted November 20, 2018)

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